Annals for Hospitalists - September 2022
Authors: David H. Wesorick
Journal: Annals of Internal Medicine (2022)

Web ExclusivesSeptember 2022Annals for Hospitalists - September 2022FREEDavid H. Wesorick, MDDavid H. Wesorick, MDFrom Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWHO202209200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Inpatient NotesClinical Pearls—Updates on Clostridioides difficile Infection for Hospitalists—Daniel Marino, MD, MBA, and Collen R. Kelly, MDIn this month's commentary, our authors provide a clinical update for hospitalists.Highlights of Recent Articles From Annals of Internal MedicineIn the Clinic: Deep Venous ThrombosisAnn Intern Med. 2022;175:ITC129-ITC144. Published 13 September 2022. doi:10.7326/AITC202209200In this review article, the authors provide an overview of the prevention, diagnosis, and management of deep venous thrombosis (DVT).Key points for hospitalists include:Direct oral anticoagulants (DOACs) are the drugs of choice for treatment of DVT, except for patients with advanced renal failure or those with antiphospholipid syndrome (in which case, warfarin should be considered).In patients with cancer-associated DVT, the drugs of choice are low-molecular-weight heparin or DOACs. Compared with low-molecular-weight heparin, DOACs have similar or increased efficacy but may be associated with increased bleeding, especially in patients with gastrointestinal or genitourinary cancer. Low-molecular-weight heparin is recommended over DOACs in patients with unresected gastrointestinal lesions, platelet count less than 50 × 109/L, recent life-threatening bleeding, high-risk intracranial lesions, Child–Pugh scores of B or C, and concomitant use of antiplatelet agents.Duration of anticoagulant therapy for a first episode of DVT is determined, in large part, on whether the thrombosis was provoked or not. Patients with a major, transient risk factor can stop anticoagulation after 3 months, whereas all men (and some women) without such a risk factor should continue indefinite anticoagulation (the HERDOO-2 score can safely identify a subset of women who can stop anticoagulation in this circumstance).Thrombolytic therapy is generally reserved for patients with limb-threatening ischemia (for example, phlegmasia cerulea dolens), as there is not strong evidence that it improves symptoms or mortality in patients with DVT.Clinical Practice Guidelines From the Association for the Advancement of Blood and Biotherapies (AABB): COVID-19 Convalescent PlasmaAnn Intern Med. 2022;175:1310-1321. Published 16 August 2022. doi:10.7326/M22-1079This guideline, written by a panel of experts, is based on 2 published living systematic reviews.Key points for hospitalists include:The only strong recommendation advanced in this guideline is against the use of COVID-19 convalescent plasma (CCP) for unselected hospitalized patients with moderate or severe disease.All other recommendations are rated as weak, including the following:A recommendation for using CCP in outpatients who are at high risk for disease progression.A recommendation for using CCP in inpatients who lack SARS-CoV-2 antibodies (measured at the time of admission). In this population, CCP decreased the need for mechanical ventilation or mortality compared with standard care or placebo.A recommendation for using CCP in inpatients with preexisting immunosuppression. In this population, CCP decreased mortality compared with standard care or placebo, although the subgroup difference was not statistically significant. Editorialists note that, against the backdrop of evolving population immunity (from both infection and vaccination) and other emerging therapies, the clinical role for CCP remains uncertain.Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation: A Decision AnalysisAnn Intern Med. 2022;175:1230-1239. Published 16 August 2022. doi:10.7326/M21-4653This study used a Markov model to estimate the outcomes of using left atrial appendage occlusion (LAAO), compared with anticoagulation, in patients with atrial fibrillation. Benefit was determined by calculation of quality-adjusted life-years, the primary outcome. The analysis suggests that LAAO would be preferred over anticoagulation for a patient with higher bleeding risk and lower stroke risk. However, that benefit became less certain at higher stroke risk or lower bleeding risk. For example, at a HAS-BLED score of 5 or greater, LAAO was favored over anticoagulation in more than 80% of the model simulations for patients with CHA2DS2-VASc scores between 2 and 5, but that percentage decreased for lower HAS-BLED scores or higher CHA2DS2-VASc scores.Key points for hospitalists include:This study demonstrates that the benefit of LAAO over anticoagulation for stroke prevention in atrial fibrillation depends on a calculation that considers both the bleeding and ischemic stroke risk. The authors suggest that these data may be helpful in deciding between these 2 preventative strategies in individual patients.An editorialist points to several limitations of the study (including questionable model assumptions, ongoing evolution of devices and techniques, lack of long-term data related to LAAO, and the use of warfarin [rather than DOACs] in the relevant studies) and concludes that further research will be needed to determine which patients will benefit from LAAO.The Latest Highlights From Journal ClubDoes COVID-19 illness increase the risk for diabetes?Patients surviving COVID-19 had increased risk for incident diabetes vs. persons without COVID-19Ann Intern Med. 2022;175:JC93. doi:10.7326/J22-0052This study compared the incidence of diabetes in a cohort of patients who were alive 30 days after a first positive COVID-19 test result (n = 181 280) to a contemporary control group without COVID-19 illness (n = 4 118 441) and found that COVID-19 illness was associated with a significantly elevated risk for diabetes that increased with the severity of the acute illness.Sign up here to have Annals for Hospitalists delivered to your inbox each month. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: David H. Wesorick, MDAffiliations: From Michigan Medicine and VA Ann Arbor Healthcare System, Ann Arbor, Michigan (D.H.W.)Disclosures:Authors have reported no disclosures of interest. Forms can be viewed at http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-2807. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals for Hospitalists Inpatient Notes - Clinical Pearls—Updates on Clostridioides difficile Infection for Hospitalists Daniel Marino and Colleen R. Kelly Metrics September 2022Volume 175, Issue 9Page: HO9 ePublished: 20 September 2022 Issue Published: September 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.Loading ...